Seven Keys to Success to Improve Out-of-Network Collections

According to Richa Singh of Collection Rx, 5-10% of healthcare revenue is lost due to lack of time and technology associated with the work involved to follow up on the cost of collections resulting from unprocessed claims, missing documents, and denials. In many instances, providers overlook claims that are not properly processed and, as such, miss out on revenue. More importantly, almost 40% of that revenue loss is in individual out-of-network claims, mostly due to inexperience with these types of claims as a result of no data with the payers and no time or staff to commit to understanding their rules let alone track down the revenue.

Many providers don’t play in the out-of-network space or write-off a big chunk of revenue to close out an aging A/R. Yet with so many stringent rules for in-network, the biggest revenue growth opportunity exists in out-of-network care! So what does an organization need to do in order to maximize reimbursement in this arena?

1. Understand Payer Tactics

Payers, unfortunately, have cost containment practices on what they consider unnecessary tests or treatments. When these services or payment are not contracted or clearly understood, providers miss out. You need to:

• Know a payer’s out-of-network payment trends and policies• Have access to the data to prove a payer’s inadequate reimbursement • Be persistent• Dedicate the right resources with your efforts

Getting ahead of these roadblocks with technology to support your efforts of clean claims, maintain proper documentation, provide medical necessity, show submission of claims, and decipher EOBs will help increase out-of-network reimbursement.

2. Invest in Technology

Data and automated workflow rules will help improve your overall reimbursement rates and ensure you get paid for your services. Areas of suggestion include:

Avoid missed revenue with automated workflow and checks and balances throughout the collection process.

4. Streamline Your Workflow

Identify weak links in the front-end of your A/R to avoid issues on the back-end, improving staff time management and reducing the cost to collect.

5. Gain Expertise in Out-of-Network Benefits/Payments

Drive business decisions by having access to actionable data that will allow analysis, such as root cause identification on underpayments and denials, and help identify trends, projections, and revenue impact on a weekly, monthly and even ad hoc basis to help improve financial performance.

6. Gain Out-of-Network Expertise

With a growing market of unrestricted contracts in out-of-network, there is an untapped opportunity to increase reimbursement rates and impact your bottom line. You need to know the trends and tendencies of out-of-network payments, have comparable data to counter tactics, and understand those tactics.

7. Outsource Payer Collection Efforts

Ensure your partner is provider-centric in that it is providing access to your collection data, helping you with reporting and understanding metrics of importance, and offering frequent success and troubleshooting reviews.

8. Enhance Patient Experience

Pricing transparency has been shown to improve collection efforts for self-pay patients. When a patient is aware of their financial expectations sooner, labs and the ordering physicians can avoid the run-around that often results from “surprise bills.”